Shoot Up: Everyone’s Watching

A controversial Vancouver drug program gains ground, marking the frontlines of a new synthetic opioid epidemic

by Abraham Gross

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Windows above Insite, the first legal supervised injection facility in North America

There is one place in North America where the government fights drug use by funding it. To learn more, I went to Vancouver’s Downtown Eastside.

Vancouver is a city of contrasts. In it, one of Canada’s poorest neighborhoods is only blocks away from one of its wealthiest, yet the signature teal towers of the city – luxury apartments with balconies catching the salty Pacific breeze – seem a world away from the grubby Downtown Eastside. Tourists exploring the trendy Gastown know to avoid the place where the quaint brick streets dissolve to cracked asphalt. Pass it, and cosmopolitanism gives way to the Eastside’s ramshackle shops, cardboard-carpeted sidewalks and seedy bars. The neighborhood encompasses a dozen blocks crossing East Hastings Street, a main artery of the city where drivers peer from their windows. Drugs are a part of the landscape: Pills and powders are peddled from boarded shops, in dealer-laden alleys and on the streets. Many die here – more are dying than ever before.

A long queue forming in the shadow of a nondescript three-story building points to what appear to be a storefront door. A needle logo is etched on the glass, below a welcome sign. “Don’t shoot up by yourself” is painted on a window above, next to hanging hockey jerseys. This is Insite, the first supervised injection facility, or SIF, in North America. Here, users walk in from the street to legally inject illegally obtained drugs with medical supervision and clean supplies. In fourteen years of operation, Insite has had over three and a half million visits from 18,000 individual users, and despite heroin’s ever-growing death toll in Vancouver’s Downtown Eastside, the facility has a 100 percent survival rate. That track record has gained the attention of hopeful politicians and drug policy reformers in the US struggling with their own drug emergencies. The CDC has declared opioid overdose a national epidemic. Deaths due to this highly addictive class of drugs, ranging from prescription pain killers to illicit narcotics, has quadrupled in the US since the turn of the millennium. Opioids now claim over 50,000 deaths annually, more than either car crashes or guns. But what’s ravaging the Downtown Eastside is not just more people sliding from popping pills to pushing plungers, or cheap heroin filling the streets. What’s forcing leaders from city hall to the highest offices of Parliament to rethink the war on drugs is a curious fact about heroin itself: it is changing colors.

I squeezed past the crowd at Insite’s doors with Darwin Fisher, a manager at the facility. His athletic physique, slick dark hair, disarming smile and practiced lyrical enthusiasm make him a welcoming host. He walks me through the process: first, a user enters a packed waiting area. At the reception desk, staff members approach newcomers about why they’re visiting. Treatment? Detox? Curiosity? All are fair play. Everything is tailored to feel relaxed and nonjudgmental, so users fresh off the street feel no barriers. “If you want to look at barriers, walk into an emergency room or a clinic,” Darwin said. “Walk past the security guards, walk through a bureaucratic intake, sit on your hands, be very quiet, don’t be demonstrative that way, things like that. That approach just doesn’t work.”

Visitors coming for the injection room are paired with a staff member, who runs down a two-page document, explaining the do’s-and-don’ts of the service (do bring your own drugs, take as many hits as you may need, and ask for guidance; don’t share needles or disturb other users or staff). The document is also a waiver, signing off on the risks associated with drug use. Not comfortable sharing your full, legal name? Use an alias – Henry, Harriot, Heroin Ninja (actual example) – and the staff will respect it.

From there, a visitor reaches the injection room, a large open space with 13 booths. Each cubicle is a well-lit metal counter equipped with supplies – rigs and clean water for cooking, sterile swabs for disinfecting, and of course syringes still in their orange plastic packages. The booths are mirrored, partly to help users find a vein and partly for uniformed nurses to watch from behind a desk across the room. They’re armed with stat monitors, oxygen tanks, and a bounty of Narcan – the brand name for naloxone, medication which can almost instantly reverse overdose. Still, the environment is far from tense. Staff members walk from booth to booth to touch base with users, equally content advising on safer injection practices as they are chatting about the latest hockey game. Users can come down from their high in the comfortably furnished ‘chill out lounge’ nearby, clearing injection booths for others on line. Above the hum of ventilation clearing away the fumes, speakers whisper soothing tunes.

A policy of user anonymity doesn’t mean Insite lacks meaningful data; Fisher’s office at the end of the hall is a treasure trove. Ever since he joined a year after the facility opened in 2003, he has kept a log of all the drugs used by visitors, one of the few mandatory questions on the two-page waiver. Fisher opened the database on his desktop computer and scrolled down the list, one eye on the four-panel screen beside him monitoring the injection room. He’s curated a long, sometimes exotic catalogue: benzos, morphine, cocaine, even crystal meth, often in a narcotic cocktail. The most common entry is heroin, often under its street name ‘dope.’ Straight dope is a muddy brown, but in recent years more users at Insite are loading their sterile, government-funded syringes full of purple and charcoal black. Heroin owes its new palette to synthetic opioids fentanyl and carfentanil, dozens to hundreds of times more potent and powerful than heroin. They’re cheap and easy to mix in with street dope. Though hue is a giveaway, many users don’t know if they have a lethal dose in their drugs because their dealers don’t either. And since Insite began offering drug testing last July, they’ve been found in nearly 90 percent of heroin.

“There used to be days where we wouldn’t have any OD’s,” Fisher said wistfully. “We don’t see that anymore.” In the past, he told me, a bad month here was 40 overdoses; now, he sees hundreds. The potent synthetics are straining the limited resources of Insite, itself only a microcosm of the larger crisis in the city and beyond. This souped-up heroin is complicit in doubling opioid-related deaths throughout British Columbia in the span of a single year, and they are being found as far away as the streets of Toronto. Synthetic opioids are going international too, pushing New York City to a record 1,000 overdose deaths in 2016. From Montreal to Seattle, officials are scrambling to support SIFs and other more controversial drug reform policies in response to the surging overdose rates. Though they share a border and a crisis, Canada and the U.S. are neighbors increasingly divided by different political, legal, and cultural relationships with drugs. Despite this, the fate of SIFs in Vancouver may predict the future of drug reform in both.

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To find the person who is perhaps most responsible for bringing supervised injection to North America, I walked a few blocks west of Insite towards the Vancouver Lookout observation deck. Dreary dive bars give way to artisanal cafés frequented by students of Simon Fraser University. Nestled out of view on the second level of one building in the University’s scattered campuses is the Canadian Drug Policy Coalition, a drug reform advocacy umbrella group. From the conference room, executive director Donald MacPherson gazed out at the harbor and the northernmost part of the city nuzzling the base of the snowcapped North Shore Mountains. MacPherson, 64, is a grandfatherly type: lanky, bespectacled, white-haired. He regarded the approaching ferries and yachts with calm eyes and told me, “That’s where the drugs come in.”

MacPherson was no drug policy guru when he arrived in Vancouver in 1987. His academic background was in social science and education, and what little experience he had with drugs was smoking bud as a teen and college kid. Working in the Carnegie Community Centre on the corner of Main and Hastings, the heart of the Downtown Eastside, was a crash course like no other. Just as MacPherson settled in the area, the blocks surrounding the Carnegie became known as the ‘killing fields’ of an opioid crisis that drew international attention. It was the start of a five year climb in overdose deaths across B.C., from less than 40 to more than 300 by 1993. As he climbed the ranks from education programmer to director, MacPherson grew alarmed at the rapid deterioration of the community. Drugs were openly sold and used. Vacant storefronts masked the opioid dens within. Telephone poles pinned with a cascade of dirty needles were a common sight. Users died daily in alleys from overdose and disease, practically on the doorstep of the Centre. Overdose was the leading cause of death among ages 30-49.

Despite the magnitude of the crisis, MacPherson saw little official action. “This went on for years, all through the ‘90s, with very little response,” MacPherson said. “There didn’t seem to be anyone in charge.” The public disorder created by the open drug scene spooked the Vancouver Police Department to the point that officers rarely dared venture outside their cars for foot patrol. Still, the problem continued to be treated as a cut-and-dry law enforcement matter, an approach going back a century to crackdowns against the Downtown Eastside’s Victorian-era opium factories. The only alternative to arrest was abstinence treatment, and arrests were more common. Larry Campbell, then-watch commander for the Mounted Police in Vancouver, notes in his collaborative work on the history of the Downtown Eastside, A Thousand Dreams, that police in the ‘70s and ‘80s broke down many hotel room doors to bust users. He usually left weed smokers alone to focus on harder drugs and big dealers, though many of his prohibition-purist colleagues were not so forgiving. The enforcement model had so dominated prevailing drug policy that by the time police became penned-in to their cars, there were few if any approaches to fill the vacuum. When Campbell joined the B.C. Coroner’s office, responsible for cataloguing and analyzing the province’s dead, he began focusing more on the preservation of life than the law. And for a user in the Downtown Eastside in early ‘90s, staying alive became an active struggle as purer cocaine and heroin racked up a body count the Coroner’s office had never seen before.

The 1994 report by Campbell’s boss, B.C.’s Chief Coroner Vince Cain, was a turning point. A former Canadian Mountie superintendent and a respected law-and-order type, Cain denounced the “revolving door of arrest, detention, parole and relapse,” calling the drug crisis a health and social epidemic rather than just a failure of policing. “While a portion of the drug problem will remain a law enforcement problem,” he wrote, “the time has surely arrived for society to re-examine, re-define, and clarify the balance between public safety and harm reduction.” Cain’s recommendations for decriminalization of not just marijuana but small amounts of harder drugs, even advocating prescription opioids, was ahead of its time. The War on Drugs was in full swing in North America, and anything less than abstinence from drugs was treated as a concession to a criminal and moral evil: as one senior Vancouver drug-squad officer at the time proclaimed, “We want a drug free society.”

For MacPherson, whose Centre held a public hearing for Cain and contributed to his study, the final report spoke to his experience with the realities of the street. The old paradigm of arrest and punishment held sacred across North America was not stopping overdoses or preventing the spread of diseases. The problem in Vancouver was too large to be policed away, too complex to be treated with abstinence alone and too dire to be ignored. MacPherson recognized that the Cain report mapped out a new way forward: harm reduction, or prioritizing the health and wellness of users rather than policing their use. But for years, the results of the report were largely neglected, and MacPherson recognized the bud of drug reform would wither without support. He needed an advocate with power and finesse to take the city down the path. He needed Mayor Philip Owen.

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I met Owen in January at the high-rise he calls home, on the water’s edge of the well-to-do residential neighborhood of Yaletown. At 84, age and MS has taken a toll on the once sprightly mayor. He leaned on a walker. His voice is polished, but his delivery halting and repetitious. Still, he spoke clearly and proudly of his compassionate conservative approach to governing when he joined the Vancouver City Council in 1986. Owen had the privilege to retire into the physical embodiment of his life’s work. He showed me around the 120-acre plot, originally all government-owned land. The developers were offered licenses by the city council to build taller luxury condos and co-ops in exchange for providing non-market social housing and facilities for the underprivileged. Owen pointed to the base of a turquoise spire glistening in the evening showers, at a gated playground. It’s for a women’s shelter, he explained. “I mean, who’s the loser in that? Nobody. Everybody wins.”

The shoreline of Yaletown

Despite his liberal ruminations, Owen was a firm law-and-order politician when he became Vancouver’s 36th mayor, an unlikely ally to the cause of MacPherson and the denizens of the Downtown Eastside. His father, Walter Stewart Owen, was in his time the youngest Crown Prosecutor in Canada, before heading the Canadian Bar Association and eventually serving as lieutenant governor of the province. Philip’s grandfather rode with the Pacific Northwest Mounted Police and served as a prison warden. Owen won the election as a candidate of the Non-Partisan Association, a center-right municipal party. In the colorfully titled Raise Shit, a published compendium of news clippings and archival material documenting the lead-up to Insite, MacPherson and fellow activists catalogue Owen’s early conservative positions on drug policy. Owen praised mandatory life sentences, believing the courts should “throw away the key” for convicted drug dealers. Asked in 1998 about the idea of supervised injection, Owen said “I’m totally and violently opposed to this at this point. It’s absolutely wrong.” Four years later, Owen would successfully lead the charge to open the first SIF in North America.

For all his stalwart public stances, Owen was privately willing to engage the issue. He told me that on rainy nights, he would swap his dapper pinstripe suits for umbrella and civvies and head to the Downtown Eastside to chat with users about their stories and the kind of help they needed. Their responses were eye-opening. They endured daily struggles for survival, friends and family dying in the streets, using dirty needles to inject dope cooked with toilet water from public bathrooms. Individual tales were harrowing enough, but the numbers told a larger story. In 1993, the year of Owen’s election, a rush of cheap crack cocaine led to almost 400 deaths across the province, an unprecedented spike largely within the Downtown Eastside. With time, the overdose deaths filling the logs of B.C. Chief Coroner’s office, now headed by Campbell, wasn’t the only crisis. Intravenous drug users became the largest single source of new Hepatitis C and HIV infections in the province. A study for the B.C. Centre for Disease Control estimated that by 1997, nearly a quarter of injection drug users in Vancouver tested positive for HIV, and nine out of ten for Hep C.

“I was just absolutely lying awake at night, my eyes open, just shocked at what I was hearing,” Owen said. “And that’s when I started to realize that the user is sick, and the dealer is evil.” For Owen, the distinction was an epiphany. “You can separate the users from the dealers, and put the users in the healthcare, put the dealers in the criminal justice system. And that seemed like a good separation.” MacPherson, already close to the deputy city manager and head of social planning for his work in the Downtown Eastside, spoke a language the mayor understood, one which viewed drug use not simply as a criminal matter but a health crisis. Owen moved MacPherson to City Hall in 1997 and declared a public health emergency. Still, a new way to define the problem wasn’t a solution in itself. “It was more of a political proclamation,” MacPherson said, “because no one really knew what to do.”

Now that the community leader had the mayor’s ear, MacPherson needed the right voices to plot a comprehensive new vision for drug policy. He looked to the other side of the Atlantic for guidance. European cities, facing similar challenges of open air drug markets, rampant overdosing and an HIV epidemic, led the new path forward. “Drug policy didn’t change at the national level,” MacPherson explained, but rather on the level of cities, because “that’s where the rubber hits the road, the shit hits the fan: on the city level. They know the problem better than anyone in your state capital or in your federal government.” Municipal drug czars in Zurich, Amsterdam, Frankfurt and other cities rose to political prominence, dragging harm reduction from the cloisters of academia into the spotlight. Harm reduction, or minimizing the harms associated with drug use rather than the drug use itself, had existed for years before, but only became government policy in the late ‘80s and ‘90s during times of crisis. Harm reduction was discussed as a new way forward for drug policy, shifting the focus from demonizing or criminalizing drug use and drug users to treating its symptoms more as a public health emergency. The first ‘consumption room’ opened in Berne, Switzerland, in 1987, and spread from there across the continent. A common pattern followed: the march of disease was slowed, and overdose halted in its tracks.

Each city functioned as an independent laboratory for the new approach – opening needle-distributing syringe exchanges and SIFs – until 1990, when European municipal leaders, largely from Switzerland, signed the Frankfurt Resolution. The Resolution declared that a “drug policy which attempts to combat drug addiction solely by criminal law and compulsion to abstinence and which makes motivation for abstinence the prerequisite for state aid has failed.” A new approach of harm reduction would include syringe exchanges, methadone maintenance programs, and ‘good health rooms,’ or SIFs. Beyond creating a clear mandate for drug reformers, the Resolution unified the municipal leaders into a larger harm reduction movement. The signatories later formed the European Cities on Drug Policy, and the first international conference on harm reduction was held that same year in England.

MacPherson immersed himself in the burgeoning international movement. He even used his sister’s frequent-flyer miles to trek across the Atlantic to attend harm reduction conferences and meet municipal drug czars. These European leaders often came back to Vancouver speak to Owen and members of the community, including city council. I asked MacPherson if he ever felt out of his depths on all this. “Oh yeah, all the time, all the time,” he said matter-of-factly. “But I knew there was radical thinking out there that had worked, and I wanted to push it here.” Owen, swayed by MacPherson’s knowledge and municipal-oriented approach to drug reform, appointed him Drug Policy Coordinator in 2000, the first in North America. Finally, Vancouver now had a drug czar of its own.

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In November of that year, MacPherson released a draft of his masterwork: the Four Pillars. The nearly 100 page policy paper distilled the crucial lessons MacPherson had learned from abroad and grouped the more controversial approach of harm reduction with enforcement, prevention and treatment, each forming a ‘pillar’ for a new kind of drug policy. MacPherson was not the first to conceive of the Four Pillars. “We basically stole everything we did from the Swiss” he chuckled. Still, MacPherson was the first to bring the approach to the fore in North America with an official government document that had political backing.

The strength of the Four Pillars was in the packaging. The laundry list of reforms, ranging from drug education programs in classrooms to treatment alternatives for incarceration, included many policies that were not foreign and some that were already in use. That was the point: harm reduction was easier to swallow when taken with more conventional approach of enforcement. Even the radical reforms were softened. Supervised injection was embedded within this omnibus policy packet merely as a recommendation to “Establish a multi-sectoral task force with representation from all levels of government to consider the feasibility of a scientific medical project to develop safe injection sites.” It’s hardly stirring language, as MacPherson was the first to point out. “It’s the mildest, tentative, mealy-mouthed recommendation you’d ever find,” he explained, a rhetorical massaging of political concerns across the various agencies of government through the “strategic alignment of wussy language.” For the drug czar, good politics makes good policy.

The city still needed convincing, so Owen turned to politicking. He and MacPherson held nearly three-dozen meetings in city hall and around the Downtown Eastside to persuade reluctant council members and average citizens. “The Four Pillars document really became a massive public education program more than anything else,” MacPherson reflected. Presentations would follow the same basic script: MacPherson would present the Four Pillars, often with the Mayor, a kind of dog-and-pony show. Then a panel of four people, each representing a pillar, would discuss their section in detail. Often, local police officers talked about enforcement and health authorities about treatment and prevention, while drug czars from abroad spoke for harm reduction. Then the audience was given their turn at the microphone. People would stand to speak about loved ones they lost or share their own stories of substance use. “It was like a revival meeting, in a way,” MacPherson joked, but there was serious political calculus at work. “The Four Pillars meetings were really trying to build a big tent to support this program.”

The meetings helped connect those within city hall to the grassroots activism outside. Drug users, frustrated at the lack of government action and convinced no one else would speak out for them, organized their own vocal groups. One of the most influential was the Vancouver Area Network of Drug Users, or VANDU. I met its co-founder Ann Livingston just outside of the Carnegie Community Centre. Her grey, parted hair and rimless glasses barely mask the intense, steely gaze of a veteran guerilla-activist. When Livingston moved to the Downtown Eastside in 1993, she was a mother of three who had recently separated from her husband. Though not a user herself, she came to Cain’s public hearing in the Centre and called it “a spectacle to behold.” She, like MacPherson, had finally found someone who saw the overdoses and the needles lining the streets – the same streets Livingston’s children walked on – and grasped that something new had to be done.

VANDU strove to foster a community for those in the Downtown Eastside who felt abandoned by the rest of society. The group instructed users on cleaner and safer ways to shoot up, but soon discovered through open forum discussions that what people most desperately needed was a safe place to inject with clean supplies and medical support. Livingston, seeing users she knew from the neighborhood die every day, opened several illegal SIFs throughout the Downtown Eastside in the ‘90s, often spending her own money to purchase clean needles and run sites out of storefronts. When landowners kicked them out, Livingston improvised by setting up an injection site for users in a van. “You can’t imagine anything more rudimentary,” she said. Operating outside of the law wasn’t sustainable – they needed official support for a permanent solution. Increasingly, the group made a public case for the issue, through events like pitching 1,000 crosses into Oppenheimer Park, an infamous open-air drug market in the Downtown Eastside, to represent the dead.

Public stunts only went so far, though. Users needed to take their case into city hall, and the Four Pillars forced the city council to listen to their stories just as Owen had done on those rainy nights in the Downtown Eastside. It could get contentious, as captured by the documentary Fix: the Story of An Addicted City. At one meeting, VANDU activists marched into city hall carrying a mock coffin. One member wore a crude grim reaper outfit. “If one of you were dying every day, if every morning you woke up and there was one less person working in city hall, I tell you that problem would be solved in two minutes,” VANDU president Dean Wilson yelled into the mic.

“I got hell about it from other council members,” Owen recalled. “I said ‘well, they’re screaming and yelling: let’s hear what they’ve got to say. So everybody on council, just sit on your hands and be quiet and listen.’ ” Grassroots activism from VANDU and similar user groups like it were a potent force pushing City Hall to action, but they weren’t the only voice on the issue. Politically powerful business groups of nearby Gastown and Chinatown were vocally opposed to the idea of a place for addicts to shoot up near them, holding anti-SIF rallies and parading signs in English and Mandarin saying “No more drugs! Enforce the law!” They were skeptical of the philosophy of harm reduction. “People say drug injection sites are going to save lives because there are all these deaths from drug injections. Bullshit!” anti-SIF crusader Bryce Rositch said bluntly. “People die of drug overdoses because they inject drugs. If you encourage them or support them to continue to use drugs, there’s a greater chance that they are going to have a drug overdose.” Yet, research from Europe underlying the Four Pillars showed that SIFs prevented overdose, reduced fatalities in the surrounding neighborhood and cut costs without increasing drug use. But the real roadblock wasn’t the logic but the politics of SIFs. For all the work of Owen, MacPherson and VANDU, they still needed a strong group to help remove the stigma around drug use and persuade the conservative members of the council to treat the issue as a health crisis. They needed a sympathetic face, and the Ruttan family provided just that.

They were well-to-do and respectable: Rob Ruttan was a Crown attorney whose family resided in the high-end West Side. But the Ruttans were not entirely removed from the problems of the Downtown Eastside. On many nights, they saw their neighbors patrol East Hastings Street to make sure their kids had not yet died from heroin or crack. After years of this, they and their neighbors concluded that drugs could no longer be a family affair: they needed official action. From Grief to Action, an advocacy group for parents of users, formed in 2000, and along with a spike in deaths that year pushed City Hall to action. For Livingston, whose VANDU group often worked with the Ruttans, middle-class oomph made a huge difference for the cause of SIFs. “They said ‘if there’s injection sites in the Downtown Eastside, my kid will go to them and they’ll be safe in their drug use rather than injecting in an alley with a bunch of people they don’t know.’ ” Drugs crossed class and political lines, and the weight of affluent voices tipped the scales.

Public support had built to a fever pitch, and even reluctant council members could no longer fight the Four Pillars. Drug use was a public health issue that required a response. Owen, the once-conservative mayor, had credibility across party lines, and was bolstered by a strong and unlikely coalition of users, middle-class families, health experts and law enforcement. With the city behind him, other branches of government were loath to interfere. “If the police are prepared to say that they will regard it as part of the harm reduction model rather than the enforcement side, then Health Canada will not stand in their way,” Federal Health Minister Allan Rock pledged. The Vancouver Police Department wouldn’t publicly sign off on supervised injection, but ultimately endorsed most aspects of the plan. There were minor political compromises made – greater emphasis on treatment, shuffling the enforcement section in front of harm reduction – but overall, the Four Pillars remained intact. In May 2001, the city council presided by Philip Owen voted on adopting the Four Pillars. It was approved unanimously. Two years later, Insite, the first legal supervised injection site in North America, opened.

Owen told me he retired due to health; he had, after all, been the longest serving mayor in the city’s history, but the truth is more complicated. The third-term mayor had grown increasingly consumed by the drug issue, which had worsened under his tenure, and members of the NPA party had grown fed up with Owen’s changing stance from law-and-order to harm reduction. After party leaders stated he would have to compete for the party’s nomination, Owen decided not to run. Larry Campbell, the former B.C. Coroner who had spent years watching the death toll rise, decided to run for the office, though he offered to support Owen if he ran as an independent. Owen declined: the nearly 70-year-old mayor saw that the mayoral hopeful was “on the same page” with him on SIFs, and felt his legacy would be protected. Campbell, though new to politics, took up the cause of the Four Pillars under a different party and pledged to open a supervised injection site if elected.

The election was a political upheaval for the NPA, with Campbell not only easily winning the mayoral election but also securing eight of the ten city council seats for his Coalition of Progressive Electors party. Both Owen and Campbell see the results of the election as vindication of their approach. Though Campbell ultimately opened Insite, he maintains that most the heavy lifting was over once he strolled into office. “Insite came into being because of Donald and Philip,” he told me from Ottawa, where he has served as Senator since 2005. “The tough part came before I got elected mayor.”

Though Owen paid a price for his embrace of harm reduction, the once tough-on-drugs mayor had accepted the risk for what he saw as the greater good of drug reform. In one interview captured in Fix, only a few weeks before the Four Pillars were adopted, Owen was asked about the political costs of countering members of his own party on the city council. His response, cool and collected, was “I’m not looking at the next election: I’m looking at 20, 40, 60 years down the road.”

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Ann Livingston led me past the corner of Columbia and East Hastings Street on a frigid January day, 14 years after Insite opened its doors. Behind the bustle of a street market, I made out a large tent and a trailer. To get there, we rounded a corner and journeyed through an alley of users and dealers to discover the injection site Livingston and other community members have run since September, largely with funds they gathered from online donations and their personal savings.

In the tent, users were given sterile injection supplies from plastic containers atop foldable tables. But this was not Insite. For one, it was not just for injections. The tent was filled with the smoke of crack and meth. There’s less procedure too – no waivers, no logs or databases or closed-circuit cameras, which also meant fewer and shorter lines. Staffer Melissa Patton told me that those waiting in the cold to get in to Insite often come here instead. The VANDU site was crowded not just because of its convenience, but also its hospitality. Most of the staff at the pop-up were current or former users, working for small stipends paid through VANDU. Patton was not a user, but knew most of the clientele from her other jobs at an overdose prevention site and a methadone treatment program nearby. More importantly, she related to them – she had experienced the personal trauma, poverty, and homelessness of many users. Informality and familiarity at the pop-up site fostered a community for users who don’t trust many people. “Everybody knows everybody,” she told me. “These are no longer just numbers, they’re people.” As we spoke, a man in a fine coat approached her from the alley.

“May I use a chair?” he asked.

“Sure,” Patton responded brightly, “what are you using?”

“Heroin and a foil,” he replied, referring to a method of cooking heroin in tinfoil before loading it in a syringe. He made his way to an open seat in the tent.

The site lacked luxuries. I headed inside the trailer to escape the chill only to find it a dark, freezing metal box. Intermittent electricity left space heaters lifeless and the stringed Christmas lights dim. Users injected by candlelight. At one of the eight tables, the staff draped a blanket over a man shivering in his seat, careful not to knock over his crack pipes. “Can you jug?” a sandy-blonde woman called over to them. She meant injecting through the jugular vein in her neck, a dangerous but effective way for users to shoot up if they can’t find a vein or the regular hits of dope through the arm just aren’t enough. She motioned dejectedly at the used needles sprawled on the table. “I’ve had three of these and I can’t get high.” A fellow user volunteered. She prepared the syringe, flicking at the end to remove any air bubbles before piercing the neck of the sandy blonde lying supine on the floor of the trailer. I looked around and noticed a scheduler for Narcan training sessions, every day filled in red marker. When I turned back to the blonde, she was still and quiet.

All this was technically illegal. The pop-up, unlike Insite, did not have an official exemption from the federal Controlled Drug and Substances Act that permits harm reduction advocates to facilitate drug use without fear of arrest. Although officially illegal, the site wasn’t exactly underground: it’s publicly known and reported on. Medical units were called for ODs and other health emergencies that can’t be treated with the resources on-hand. Patton recounted that, just a week before, the police were called in on one user who flew into a psychotic rage, bashing his head against the trailer and smearing blood everywhere. Law enforcement has known about the site since it opened, but as a sergeant from the Vancouver Police Department put it, it’s a matter for the health authorities.

A typical kit given to users at a supervised injection site includes sterile water, cooker, filter, swabs, tourniquet, and of course a clean syringe

The odd realm of illegal-but-tolerated that this pop-up SIF inhabited can be explained, like so many SIF-related issues, by politics. Mayor Campbell had received an exemption for Insite to run under experimental status for three years with funding from the provincial health authority and staffed by the Downtown Eastside-focused nonprofit Portland Hotel Society, after which time Insite would require renewal from the federal government. But in 2005, the city was deprived of its charismatic mayor when Campbell left for the Senate. Shortly after, the Liberal administration that had tolerated the Vancouver experiment was swept out of government with the election of Conservative Prime Minister Stephen Harper. It’s not difficult to see why even the genteel Owen referred to him as “shitface”: Harper’s tough-on-crime administration was determined to undo the Mayor’s achievements by stamping out the nascent North American harm reduction experiment. His administration renewed Insite’s exemption with shorter and shorter permits, until refusing entirely in 2008, declaring war on SIFs. MacPherson, frustrated by federal meddling in the municipal-oriented approach he so prized, left his post as Drug Policy Coordinator. “Our federal government is going backwards,” MacPherson said at a drug reform award ceremony that year, his voice filled with rage. “I’ve quit my job because I can’t take it anymore.” He was not alone in his anger. Rallying together fellow advocates, MacPherson began the Canadian Drug Policy Coalition 2011 to campaign at the national level for drug reform and harm reduction.

The controversy that surrounded Insite from the start turned out to be its saving grace. As a condition for its exemption from the Controlled Drug and Substances Act, Insite was constantly scrutinized, quickly becoming one of the most studied SIFs in the world. By the time the feds took Insite to task, a flood of research published in some of the most prestigious peer-reviewed medical journals almost uniformly found the facility had an array of positive effects – a conclusion reaffirmed in the years since. Not only had Insite prevented deaths and the transmission of disease, but it had also increased admissions into detox and addiction treatment, reduced public injections and needle-sharing, taught safer injection practices and saved the health care system millions. Almost as importantly, Insite was shown not to escalate drug-related crime, increase relapse or prevent recovery, undermining opponents’ claims that harm reduction enabled users and nursed their dependence.

With this armada of scientific evidence, SIF proponents fought the government in court. A series of rulings in favor of Insite were appealed by the federal government time and again until finally, in 2011, a unanimous decision in the Supreme Court of Canada mandated the government renew Insite’s exemption. It was the government’s actions, not Insite’s, which violated the Controlled Drugs and Substances Act’s purpose of maintaining and promoting public safety. In the words of the Court, “during its eight years of operation, Insite has been proven to save lives with no discernable negative impact on the public safety and health objectives of Canada.” The vindication was short-lived, as Conservatives passed the Respect for Communities Act in 2015, adding a dizzying list of new regulations and hurdles for any future facilities. Even under the Liberal government of Prime Minister Justin Trudeau, who campaigned on legalizing cannabis, the Act has slowed the spread of SIFs.

Illegal sites like Livingston’s filled the void, much like they did before Insite opened. After all, Insite was never meant to handle all the injection needs of the Downtown Eastside, despite the facility regularly receiving upwards of 700 visits a day for years now. “The number of users will not rise much if any as the site runs at full capacity – it can’t process more people,” Russell Maynard, head of policy and research for PHS, told me. The average 35 referrals-a-month from Insite to Onsite, the detox program upstairs, has also reached its limit: there just aren’t enough beds for more users to stay in during recovery.

Long lines are a common sight at Insite

Another SIF within the HIV/AIDS clinic of the Dr. Peter Centre predates Insite but obtained legal status only recently. It barely lightens the load. The Centre is in the more affluent Westside, and designed for the needs of a smaller clientele that is distinct from Insite’s: all are HIV positive, most are on the older side, and they often carry other medical issues from coinfections like Hep C to physical disabilities limiting mobility. The injection facility also integrated into a preexisting health facility, the Dr. Peter Centre, and offers more comprehensive service than just the injection-related care, ranging from the purely medical retroviral treatments to the more therapeutic music and art sessions. The injection room is modest, off to the side and outfitted with three booths compared to Insite’s thirteen. Executive Director Maxine Davis told me that a more integrated, smaller site is lower cost and an easier choice for more typical cities where the drug scene is spread-out. The Downtown Eastside is unique. “Insite was desperately needed, the standalone, because it was a massive population that needed this service,” she said. “The intensity of the injection drug use there, anything less than the size of Insite would be too little.”

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Two legal sites in one city will not enable it to weather the impending storm of synthetic opioids. This class of drugs have been in use for many years – most hospitals are stocked with fentanyl to relieve chronic pain. But in recent years they have spread across the illegal drug market and have directly led to an explosion in drug-related deaths. In the U.S., synthetic opioids are the fastest growing cause of overdose deaths, surging 72 percent from 2014 to 2015, while heroin deaths only grew around 21 percent and prescription opioids by less than 3 percent. But the problem is most acute in Vancouver, where the morgues are quite literally stacked with the bodies of those claimed by synthetic opioids. I arrived in the city only two weeks after Cheque Day, where many in the Downtown Eastside receive their social assistance allowances. The city has grown accustomed to the routine: users, newly flush with cash, go to score a hit, and some will inevitably OD. Ambulances are on standby, services primed for crisis. But even by Vancouver standards, Wednesday, December 21st – my birthday – was especially fraught, and the neighborhood was still reeling. The city received 80 calls for overdoses in just over 24 hours. Insite treated nearly 30. It marked the deadliest month of deadliest year in the province’s long history of drug overdose deaths. Prescription painkillers are the past: Vancouver provides a glimpse into a future crisis dominated by synthetics.

The danger posed by synthetic opioids is difficult to overstate. Fentanyl, the most common, is 80-100x more potent than morphine, and users who OD on it sometimes require multiple shots of Narcan – made famous for its near-miraculous ability to revive heroin users from the throes of overdose with a single shot. But fentanyl pales in comparison to the increasingly prevalent carfentanil, from the same chemical family but nearly 100x more potent than even fentanyl and 10,000x more potent than morphine. It’s conventionally used as a sedative for large animals like elephants, and because a dose as small as a grain of salt can be fatal to people, zookeepers wear face shields and gloves to handle the drug. After a spate of carfentanil busts last summer in Ohio, the state’s Attorney General urged police to send suspected heroin and fentanyl straight to the lab rather than to test at the scene, for fear of officers accidentally inhaling or absorbing particles of the substance through the skin.

The potency that makes these drugs so dangerous is also why they’re so profitable. Fentanyl and carfentanil can be distributed in smaller amounts than conventional opioids like heroin to achieve similar highs. It’s not much cheaper for the user – a dose of heroin on the streets of Vancouver already goes for around $10, less than a pack of beer – but being able to sell more doses using less opioid material makes suppliers rich. Smaller quantities are also easier to smuggle in from China, the main distributor of synthetic opioids due to lenient regulation (fentanyl and fentanyl-analogs often go by the street name “China White”). In October of 2015, Canada Border Services Agency Officers seized 102 kilograms of fentanyl precursor, a quantity able to produce an estimated 38 million doses. Last June, law enforcement stopped a package from Vancouver International Mail Centre, originating from China and en route to Calgary. Inside was a palm-sized printer ink bottle packed with one kilo of carfentanil, capable of producing more than 50 million doses.

Over 50 million lethal doses of carfentanil. Image courtesy of CBC, via Royal Canadian Mounted Police.

The synthetics crisis has put harm reduction advocates on the map. “This year, I think we’re going to use the fentanyl situation as a chance to try and get people to start thinking outside the box,” MacPherson said before pausing our interview to discuss Toronto’s SIF applications on CTV, one of the largest news stations in the country. City leaders watching the unfolding overdose scourge are now clambering for harm reduction, and national leadership is rushing to fill the demand as applications for new SIFs come in from across the country. Montreal was approved for three sites in February, and another eight are pending for Vancouver, Surrey, Toronto, Victoria, and Ottawa, the nation’s capital. More SIFs are coming, and faster than ever before. In May, the federal government passed Bill C-37, removing many of the constraints imposed by the Respect for Communities Act on proposed SIFs and speeding up the approval process for new sites. In the meantime, countless illegal SIFs li­ke the one Livingston showed me are popping up in the hardest-hit areas.

As SIFs spread, more controversial solutions like heroin maintenance programs gain ground. Patients of Vancouver’s Crosstown Clinic are given prescription-grade heroin and heroin substitutes like hydromorphone. The program is limited to a select class of users who do not respond to conventional treatment, but is now at capacity with over 100 patients, and harm reduction advocates are encouraging their use to combat synthetics. The notion of literal state-sponsored heroin may appear radical at first, but to advocates they’re a logical outgrowth of SIFs. After all, an overdose, even if survived within a SIF, still leaves lasting damage on the body, and it’s hard for users to find dope they won’t OD on when most street heroin is laced with synthetics. Though Insite offers drug testing, few of the users whose drugs come back positive for fentanyl throw away a precious hit. In this way, prescription heroin provides the same health care support of SIFs with the added benefit of free drugs untainted by deadly synthetics. “I think we should strike while the fire is hot and say ‘heroin prescription, heroin prescription!’” Livingston told me.

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For harm reduction advocates, finding a base in the U.S. is the new challenge. American cities are facing the same crisis, and are increasingly looking to Canada for guidance. U.S. municipal leaders, learning from the Four Pillars and visiting Insite and the Dr. Peter Centre, are beginning forays into harm reduction. San Francisco’s Board of Supervisors, the legislative body of the city, is considering a bill to create a task force to research safe injection, the kind of strategic ‘wussy language’ found in the Four Pillars. In New York City, a SIF study has been underway since September. Advocates are placing bets that Seattle and nearby King County, which have approved plans to open SIFs, will be America’s trailblazers.

Supervised injection is leaving Vancouver and spreading throughout North America. Illustration courtesy of Rachel Hsu.

November 8th transformed the political landscape. Then-President Elect Donald Trump had taken a hard line on drugs early on the campaign trail, framing the issue as a criminal matter of drugs flooding in from Mexico. Candidate Trump repeatedly expressed admiration for Philippine President Rodrigo Duterte’s bloody campaign against drug dealers and users, which has since been followed by a phone call in May where Trump congratulated Duterte for his “unbelievable job on the drug problem.” When I spoke with Ethan Nadelmann in his Manhattan office in late November, he was not hopeful about the incoming administration. As the executive director of the Drug Policy Alliance, a major national advocacy organization best known for its successful campaigns for marijuana legalization, Nadelmann has been hailed America’s de facto drug czar. Donald MacPherson and Larry Campbell are both on the DPA board, and helped advise Ithaca’s Mayor Svante Myrick on his SIF proposal that splashed across headlines last September. But when we met, Nadelmann had already publicly called Jeff Sessions, longtime admirer of Reagan’s War on Drugs, “a nightmare for drug policy reform,” a characterization bolstered by the now-Attorney General’s push for federal prosecutors take the hardest line possible on drug offenses. Nadelmann told me that “all of this is going to make life more difficult.” The Harper government showed how quickly the progress of harm reduction can be set back by federal interference, and unlike Insite, SIFs in the U.S. might not survive long enough to prove themselves.

“But even under Harper, things advanced,” Nadelmann reminded me. In an attempt to find a silver lining, he pointed to Vice President Mike Pence’s initial opposition to funding needle exchanges during an HIV outbreak among drug users in Indiana when he was governor. Pence eventually retired the old fears of enabling and increasing drug use, instead funding the needle distribution, if only on a temporary basis. “The fact of the matter was, you create a needle exchange, you begin to engage active drug users not as junkies but as human beings,” Nadelmann said, and therein lies hope for SIFs. Not to mention that the Rust Belt states which gave Trump the election are also the most deeply affected by the opioid crisis. “Ethan’s grasping at straws here,” MacPherson said wryly when I recalled the exchange to him. “You got to make the best of a bad situation.”

Hedging hopes for a tolerant federal government, Nadelmann is doubling down on the municipal-oriented approach of Europe that inspired MacPherson and Philip Owen to lead Vancouver towards harm reduction. “That local model is going to become ever more important again now that Trump’s gotten elected and that the Republicans control a substantial majority of state governments now,” he said. However, the local model is struggling in the U.S., with Ithaca as a prime example. The outspoken young Mayor Svante Myrick who has lost family members to drugs had a compelling narrative for supervised injection, but nevertheless did not follow Owen’s example of winning over reluctant groups like law enforcement. Owen’s Four Pillars secured the approval of the city, law enforcement, the province, and the federal government. Myrick, by contrast, was immediately greeted with the city’s police chief disavowing supervised injection and Governor Cuomo warily declined to opine on, much less endorse, the Ithaca Plan. San Francisco Mayor Ed Lee shot down a similar SIF proposal last year, and only recently opened to the idea. In an attempt to preempt Seattle’s efforts, a bill banning SIFs is lumbering through Washington state legislature. The cause of SIFs in the U.S. does not bode well if it is flagging in the most liberal cities.

The political divide between the two nations is stark. I was not the only visitor to the Downtown Eastside’s pop-up SIF that day in January: Don Davies, a member of Canada’s House of Commons representing a portion of Vancouver, was also there, milling about with a local reporter in tow. He greeted me with a firm handshake before turning to Livingston to praise the good work of the site and advocating prescription heroin programs. “Boy, he’s a sight for sore eyes,” Livingston chirped. As an American, I find it hard to envision even the most progressive member of Congress taking a similar approach, but in Canada, harm reduction is no longer a Vancouver affair. Prime Minister Trudeau visited the Downtown Eastside in March to hear activists, including Darwin Fisher, discuss the opioid crisis and the need to expand SIFs and prescription heroin services. In the U.S., harm reduction may live in the memos of non-profits like the DPA or the occasional op-ed piece, but in Canada it is national drug policy. When Campbell spoke to me between Senate meetings about his efforts to decriminalize drugs, he constantly referred to ‘the Pillars.’ I asked him how big a role the Four Pillars played on the federal level. “It’s huge. It’s a map of how to deal with this problem: it’s comprehensive, it’s well-thought-out,” he said matter-of-factly. “This federal government has accepted the Four Pillars.”

The Dr. Peter Centre injection room may offer a glimpse into a future staple of drug treatment in North America

While harm reduction may be gaining popularity as the opioid crisis intensifies, the deep cultural stigma surrounding drugs is difficult to uproot. The U.S. still adopts a Prohibition-era stance, classifying drugs as a vice and condemning users as culpable of moral failing. Perhaps no one knows this better than MacPherson, whose efforts helped reshape the discussion of drugs in Canada from one of criminality to compassionate healthcare. “For the same reason we have trouble with injection sites as a community or as a society, we’re sort of in the dark about this whole thing for some reason. We think that prohibition is going to protect us. But it doesn’t.” The road ahead for harm reduction in the U.S. may be long, but MacPherson draws on the work in Vancouver as a guide for the future. “What the process here did was it got people talking to each other, everyone gravitated towards the moderate middle because the radicals on all sides realized that we’re trying to get something done here, we all agree we’re trying to get people some help, and that’s where we built a lot of strong support: in the middle. For trying stuff, for trying something new.”

There are now many following his example, with new harm reduction leaders looking to the epic of Vancouver in hopes of seizing the grand narrative of history away from suffering and death, a tale being written in Vancouver alleys and Ohio motels, from Canuck country to the Rustbelt. But though that past is being studied, it remains to be seen if it will truly be learned from, or if new drug crises will be addressed with the old approaches of criminalizing, demonizing, and simply ignoring the health and wellbeing of users as human beings. Ann Livingston, who devoted her life to the cause, knows the deadly cost of the slow and often uneven progress of harm reduction.

“I was here in ’93,” she said bitterly. “In 20 years, when I’m 80, are we going to do this again?”